Otolaryngology and sleep medicine fellowships.

The Residency Review Committee for Otolaryngology (OTO RRC), under the aegis of the Accreditation Council for Graduate Medical Education (ACGME), periodically inspects and certifies the 102 residency programs in Otolaryngology, 11 fellowships in Neurotology, and 5 fellowships in Pediatric Otolaryngology. The training program requirements for the subspecialty fellowships have recently been revised to minimize overlap with general otolaryngology, paring procedures such as tonsillectomy and adenoidectomy from the Pediatric Otolaryngology competencies and tympanoplasty and mastoidectomy from the Neurotology criteria.

Program requirements are updated at regular intervals to keep pace with the expanding scope of the specialty, and last year a specification for training in the "diagnostic evaluation and management" of sleep disorders was added to the core Otolaryngology criteria. The OTO RRC was not alone in its interest in sleep disorders, and last fall the RRCs for Internal Medicine, Pediatrics, Psychiatry, and Neurology formed an ad hoc committee, along with the American Academy of Sleep Medicine, to assemble guidelines for a one-year fellowship in Sleep Medicine, with encouragement from their respective boards on the American Board of Medical Specialties (ABMS). Formally proposed to the ACGME in spring 2004, the fellowship encompassed the evaluation and conservative management of the neurologic, behavioral, pulmonary, developmental, and other medical aspects of sleep disorders.

Given the strong interest in sleep medicine by Otolaryngologists at a number of university-based centers and by a cadre of Otolaryngology practitioners who have expanded beyond the surgical management of sleep disorders to disease evaluation and medical management, the OTO RRC petitioned to be included in the discussions about Sleep Medicine. Subsequent negotiations, culminating at the June 2004 ACGME meeting, secured Otolaryngologists an "equal opportunity" status with colleagues in the other four involved specialties. Not only will Otolaryngologists be eligible for a Sleep Medicine fellowship, but they also will be able to serve as faculty or as a program director for a Sleep Medicine fellowship.

The OTO RRC had the option of eschewing participation in this new fellowship and could have simply added more language regarding the medical management of sleep disorders to the Otolaryngology program requirements. This would not have been equal to a one-year fellowship, as there is not enough "free" time during the five years of Otolaryngology training to accommodate such. However, that course likely would have led to the exclusion of Otolaryngologists from the Sleep Medicine fellowships (and faculty), which in the next decade will involve most university hospitals, where medical students and the majority of residents are first exposed to this subspecialty. Attempting to block ACGME endorsement of Sleep Medicine fellowships was not a viable option, given the strong support of the four RRCs initially involved, with the backing of their respective boards. It came down to Otolaryngology either getting on board as an equal partner in the Sleep Medicine fellowship process or getting out of the way. The OTO RRC chose the former, assured that the program requirements for the Sleep Medicine fellowship would contain no verbiage regarding airway endoscopy or surgical interventions, and that overlap with the existing program requirements of an Otolaryngology residency would be minimal.

What remains before ACGME-approved fellowships in Sleep Medicine begin to appear at hospitals around the nation is a one-year period to screen applications, then a review of the best by the appropriate RRC (depending upon the specialty in which the proposed program director is board certified by the ABMS), and finally site visits and certification of a modest number of fellowships for a trial period to work out any problems. Otolaryngologists should be aware of this new expansion of our field and should look forward to increasing our expertise in the comprehensive management of sleep disorders.

J. DAVID OSGUTHORPE, MD Professor of Otolaryngology-Head and Neck Surgery Medical University of South Carolina Charleston, South Carolina